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Ee6A\F9!'s `ED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> AUG ® 7 2015 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> T�[&hone: (209) 468-3420 Fax: (209) 464-0138 Web: wvvw.sjgov.org/ehd <br /> ERMRONMENTAL HEALTH <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: A ( � �L BUSINESS/AGENCY: <br /> ADDRESS: �r�1�1to �(UG� )�• CITY/STATE//ZIP: <br /> PHONE (1): y 7�1 / ���T PHONE (2): kq 4 (93'J' ! FACSIMILE: <br /> Please allow 10 business days from date of application submittal for the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOXTO EXPEDITER LEST $130 FE CA H OR CHECK ONLY)-REQUEST PROCESSED IN 3 BU INESS AYS (0/17 <br /> SIGNATURE OF APPLICANT DATE <br /> Electronic information: ❑ List Ma scrl ion: <br /> FILE ADDRESS <br /> EHD USE ONLY <br /> street# Street Name city <br /> 2, ❑Unit t <br /> 3. r � i 41 S j (0vttlle.,S', \01c. El unit e <br /> 4. ❑Unit 2H <br /> 5. <br /> v Unit 3 <br /> F8.7 <br /> ®Unit4 <br /> IJ SITE MITIGATION <br /> 9. <br /> 10. d Unit 5 <br /> Specific Date Range of Information Requested: From to <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> DERGROUND TANK(UST)CLEANUP SITE(LOP) E]MEDICAL WASTE FACILITY LID WASTE FACILITYNEHICLE <br /> THER CLEANUP SITE(NON-LOP) ❑HOUSING ABATEMENT ❑WASTE TIRE <br /> NDERGROUND TANK(MONITORINGIREMOVAL) ❑FOOD FACILITY ❑DAIRY <br /> ABOVEGROUND TANK ❑CHICKEN RANCH]DOG KENNEL ❑WASTEWATER TREATMENT PLANT <br /> U ARDOUS WASTEIHAZARDOUS MATERIALS ❑MOTEL/HOTEL ❑PUMPER TRUCK/YARDICHEMICAL TOILETS <br /> IERED PERMITTED FACILITY �❑POOLISPA ❑LAND USE APPLICATION SITES <br /> TATTOO/BODY PIERCINGOMPLAINTIRESPONSE RECORDS ❑OTHER(PLEASE SPECIFY) <br /> WELL AND SEPTIC PERMIT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:00PM(EXCLUDING HOLIDAYS) <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted.Applications received after 3:00 pm will be processed the next business day. <br /> 2. For assistance in identifying the nature and content of EHD records,please contact EHD at the number noted above. <br /> 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. The files will be held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> r <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$130 deposit prior to review. ***BOXED AREA-EHD USE ONLY*** <br /> Cc. of `w C ix LAok75 'ts iH 4va, U,ST �Vc Lv1- rn `'t 1 5-r <br /> ❑ Records provided by Staff-PPR Complete. Staff Name: <br /> EHD 4846 711115 <br />